Hamstreet Surgery
New Registration Questionnaire (Age Over 5 years)
We would like to welcome you to our practice. The questionnaire is an opportunity for us to collect details about your current and past medical history. Please complete this questionnaire and hand back to reception.
PESONAL DETAILS	DATE:	
NAME:	DATE OF BIRTH:	
ADDRESS:	PHONE NO (HOME):
PHONE NO (WORK):
MOBILE NO:	
MARITAL STATUS:	EMAIL:	
MALE  □	FEMALE  □	OCCUPATION:	
EMERGENCY CONTACT & PHONE NO:	
NEXT OF KIN NAME, RELATIONSHIP & PHONE NO:	
DO YOU HAVE A CARER:   Yes □    No □	ARE YOU A CARER:   Yes □    No □	
If yes who……………………… ………………………….. 	Please ask for carers form.	
HAVE YOU EVER SERVED IN THE ARMED FORCES:	Yes □    No □    Date:	
ETHNIC ORIGIN:	White British  □	Black British  □	Other White  □	
Afro-Caribbean  □	Other Black    □	Asian              □	Chinese          □	
Mixed/Other  □ please state……………………………….			

SUMMARY CARE RECORD: Your basic details (name, address, allergies, list of acute and regular medications) are uploaded to the national NHS database and can be viewed by other health professionals in an emergency. If you wish to opt out please tick here □ and sign the relevant form (ask at reception if you were not given this when you registered). You can view your summary record at any time – just ask.	

Proof of Identity
	Birth Certificate 		Driving Licence		Passport		Utility Bill	
	Allowance Book		Solicitor’s Letter		Offer of Tenancy		Other		

MEDICAL DETAILS:	
Have you had any serious illnesses, operations, stays in hospital? If so please include details and year if known:
	
Are you taking any medication (including the pill or HRT)? Please give name of medication and dosing:
	
Are you allergic to anything? If so what reaction did you have?
	
If you have any records of any vaccinations you have had, could you give details here or let us see them:
	
Do you have a disability? (If so, please state disability)*
Please list any special requirements (eg hearing loop, communication needs including both written and verbal):
	
Disability includes those who are blind or partially sighted; deaf or hard of hearing; insulin-dependent diabetics; wheelchair users & difficulties walking; heart conditions; problems with continence; restricted height; arthritis; epilepsy; learning disabilities; mental health problems; dyslexia.	

For ladies:	
Date of last smear if known:	
Have you had a hysterectomy? If so, when:	
Have you ever had a mammogram?	
Could you list pregnancies, including year and any problems:

	
SMOKING HISTORY:	
Current Smoker  	□	How many per day ………………	Roll-ups ………….. oz per week	
Ex Smoker            	□	Date stopped ……………………….	
Never Smoked	□		

EXERCISE LEVELS:	
I find exercise physically impossible  □	I avoid even trivial exercise  □	I enjoy light exercise    □	
I enjoy moderate exercise                   □	I enjoy heavy exercise           □		

ALCOHOL QUESTIONNAIRE:
(please circle the answer that applies)	Scoring system:	Your score	
	0	1	2	3	4		
1.	How often do you have a drink that contains alcohol?	Never	Monthly or less	2-4 times per month	2-3 times per week	4+ times per week		
2.	How many units of alcohol do you drink on a typical day when you are drinking?	1-2	3-4	5-6
	7-9	10+		
3.	How often have you had 6 or more units if female or 8 or more units if male on a single occasion in the last year?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily		
Pint of regular beed/lager/cider = 2 units; alcopop or can of lager = 1.5 units; 175ml glass of wine = 2 units; single measure of spirits = 1 unit; bottle of wine = 9 units

FAMILY HISTORY:	
Please indicate any family history  of the following:	
		Relative	Age at diagnosis	
Diabetes	Yes □    No □			
High Blood Pressure	Yes □    No □			
Heart Disease	Yes □    No □			
Strokes	Yes □    No □			
Glaucoma	Yes □    No □			
Bowel Cancer	Yes □    No □			
Lung Cancer	Yes □    No □			
Breast Cancer	Yes □    No □			
Prostate Cancer	Yes □    No □			
Ovarian Cancer	Yes □    No □			
Other (please specify) ……………………………………………			

For patients aged 65 and over or those with a chronic disease (e.g. asthma or diabetes)	
Have you had a flu vaccination? (Enter date or “Never”)		
Have you had a pneumococcal vaccination? (Enter date or “Never”)		

HAMSTREET SURGERY PATIENT PARTICIPATION GROUP
At Hamstreet Surgery we are always looking to improve and develop the services that we provide for our patients.We set up a Patient Participation Group to involve patients in the development and planning of new services.  This has proved very helpful and hopefully our patients have benefited from this. The Group meet every two months at Hamstreet Surgery on a Tuesday evening starting at 7.00pm and finishing promptly by 8.30pm. We would welcome patients of all ages and from all areas to join the Group so that we have a good representation of our Practice population.
If you are interested in becoming a member of the Patient Participation Group please fill in your details on the slip below and return it to the surgery. 
If you would like to become a virtual member please make sure you give your email address and  tick the appropriate box.
I am interested in becoming a member of the Patient Participation Group                  
I am interested in becoming a virtual member of the Patient Participation Group                     
Email address:  _______________________________________

All information disclosed in this questionnaire will be held on our computer records to enable us to provide the best possible care. Your information is stored and accessed securely by designated practice staff only in line with current GDPR regulations. You can find our GDPR privacy notices on our website and in reception.

Date……………………………………………   Signature of Patient……………………………………………………………………………….

Reviewed 24th May 2019